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Governor Mitt Romney Remarks At The Florida Medical Association Hollywood, FL August 24, 2007 "I did say there was

a bit of irony in the fact that I’m addressing you. Here I have a room full of doctors and healthcare professionals, and I’m talking to you about healthcare. And I am used to, somewhat, this unusual setting where I am placed in a position where my skill is overwhelmingly overshadowed by the people whom I’m addressing, or I’m responsible for. When I went out to run the Olympics, as Dr. Rubenstein indicated, you have to understand that my boys felt there was a certain degree of irony in that. And that was I was not a fabulous athlete, and so when my five sons heard that I was going to run the premier sporting event in the world they acknowledged the irony. But when they saw it in the paper my old son called and he said, 'Dad, we saw the paper this morning, the five brothers and I have talked. We want you to know there’s not a circumstance we could have conceived of that would put you on the front page of the sports section.' "So there are unusual circumstances to put me before you today, but I have a pretty significant agenda I want to talk to you about, because I think there are changes needed in our health insurance world that’ll make a world of difference for the people of our country. There are a number of things I’d like to see have happen. "One is, I’d like to make health insurance more affordable. There are a lot of families in this country that are finding it harder and harder to afford health insurance. I was in Massachusetts and met a woman named Linda DeWolfe. She runs an auto repair shop there with her husband. She said they were having a very difficult time buying insurance for themselves and for their employees; it was simply getting too expensive. We need to find a way reign in the extraordinary growth in the rate of health insurance cost. "Secondly, I’d like to provide access to quality health insurance for every American. I’d like to see every American have insurance that is affordable – every American. And let me just note something, the 45 million that don’t have insurance in this country represent a small section of those people who are worried about losing insurance. Because if there are 45 million without insurance, there are a lot of other who think, ‘Well gosh, I could be in that position as well.’ That fear of losing one’s healthcare, health insurance, is something Americans shouldn’t have to feel. "And there’s also a problem with having 45 million uninsured, not just for those that don’t have the insurance, but for everybody. Because the 45 million who don’t have insurance – if they get sick they go to the emergency room for care. And that’s not ideal care, as you know, it’s not the preventative care they need, doesn’t get them the prescription drugs to stave off an acute condition developing from a chronic condition. And the cost of the health provided there at the emergency room is not paid for by them because they don’t have insurance. Who’s it paid for by? Well, by the people who do have insurance. So not having insurance is not good for them, doesn’t give them good quality healthcare – and it’s

not good for everybody else, because they’re having to pay for it, through their taxes or their premiums. The problem of the uninsured is a problem for all Americans. "There’s another challenge – portability. People are fearful that they might lose a job. If they lost a job they might lose their insurance, particularly if they have a preexisting condition, when they go to get the next job. That shouldn’t be something that Americans have to worry about. "And finally, we need to find a way to reduce the rate of growth of spending in healthcare in our country – it’s now 17 percent of our GDP. When I was a consultant in the insurance industry, some years ago in the 1980s, it was 11 percent. The idea it would get to 17 percent was unthinkable. And it continues to move northward. "Now I know some people look at that slide and they say, ‘That guy must me a Democrat up there, this is a Democrat issue.’ Well you’re wrong. Healthcare is not a Democrat issue, it’s a Republican issue, it’s a conservative issue. Democrats look at problems like this and they have one answer – government. We need bigger government they say, so we can manage problems like this. That’s the wrong answer. "Conservative principles have the answers for healthcare. I think I’m going to be able to demonstrate to you today the conservative principles of personal responsibility and freemarket dynamics and choice and personal care – these kinds of elements allow us to reform healthcare in such a way that we can solve the problems that America faces in healthcare without having a government takeover, without having socialized medicine with all its drawbacks and all its weaknesses. "Now you might all say, ‘But yeah, getting there’s going to be awfully expensive isn’t it? How are we going to get people insured if there are 45 million without insurance? Boy, that must mean you’re planning on writing a big check.’ Well, I’m not. And one insight, you already know this, but a lot of people don’t, one insight I want to make clear – we have 45 million people, you’ll hear this all the time, ’45 million people without healthcare.’ No, that’s not true. We have 45 million people without health insurance, but they have healthcare in almost every case because if somebody let’s say has a heart attack in their apartment and they have no insurance, they get picked up by the guys from EMS, they’re taken to the hospital. They’re stabilized. Maybe they do a bypass surgery, put in a stint. They’re given medication and return home. They get ongoing healthcare. So they’re getting healthcare. They’re just not paying for it. No insurance company is paying for it. Who is paying for it? Well the rest of society is. Taxpayers, the people who are buying insurance, everybody else is paying for it. The medical profession, everybody is paying for it but not the people who are sick. We have 45 million people without health insurance but they are getting care. So the money is already there. It’s already being spent and wouldn’t be smarter to take the money that is being spent on programs and on cost shifting and use that money instead to help people buy their own private insurance. Get them insured rather than just hand out care at hospitals for free.

"And my thoughts about this topic really flow from the experience I had as Governor of Massachusetts. I was in office for a short period of time and a friend came in and said, ‘Mitt why’d you run for office?’ I said I ran for office because I want to help people. And he said if you really want to help people find a way to get everyone in our state health insurance. And I said, ‘Tom, that can’t get done. I’m not going to raise taxes. I’m going to have a government takeover. I’m not putting in place Hillary care. I can’t get that done.' Well, it began to grate on me. And I thought if I were back on my private sector job, I’d be bringing in people of all different backgrounds and I would study this issue and come up with some answers. Our first year of work didn’t accomplish too much. Our second year we had a brain storm what we could do to get everyone insured with private market based insurance; not needing new taxes. "Let me tell you why we focused on the issue of health care reform in our state. We had 460,000 or so uninsured. Our premiums were high, rising fast. If you lost a job, you were afraid of losing coverage. Individuals and small businesses were having a hard time getting insurance. Seems the insurance companies are really good at marketing and servicing big companies, big groups but if you’ve got two employees. The insurance companies just didn’t have much attention to pay to you. And we were spending about $1.3 billion in our state giving out free care, payments to hospitals, and other providers that were giving out free care and that number was growing. Those were the problems. "We just began by saying just who the heck are the uninsured. We imagined that these were people who are poor and single moms. That’s what we figured we had. How are going to insure all these poor, single moms. And we found much to our surprise that that did not represent our uninsured. Frankly, the largest group of uninsured were people that were making $53,000 a year or more for a family of four. That’s three times the poverty level. These are people that could afford insurance, they just weren’t buying it. That’s 204,000 people. Low income, that’s working poor, would have a hard time buying insurance. That was about 150,000 people and much to our surprise there were 106,000 people who were uninsured in our state that qualified for Medicaid but had never signed up. "So as we looked at our population, we realized we were going to have to follow different approaches for the different types of people that didn’t have insurance. For the higher income people, the people earning over three times federal poverty, we talked to them and we said why don’t you have insurance. And they had three things roughly that they said that stuck with us. One, was that it’s just too expensive and we looked at the premiums and it was expensive. They said number two, if I’m working as a part time worker at multiple places or as I’m working as a sole proprietor, it's hard to get an insurance company that will even talk to me. And number three and this was the most troubling of all where a lot of people would say why should I buy insurance? If I get sick, I can go to the emergency room and get treated for free. Americans aren’t stupid. If we’re giving stuff out for free why pay for it. "So we recognized that we had to make some changes and one was to get the cost of insurance premiums down so people with middle incomes could buy insurance and afford

it and deregulation and market reform was one place we went to work. For low income people we said were going to put in place a principle of personal responsibility insisting these folks provide what they can towards their healthcare and the state is going to pick up the rest of the cost of their insurance premium. And finally, with regards with Medicaid eligible, we put in place a porthole on a computer that allowed hospitals and providers to instantly check whether someone was qualified for Medicaid and if they were we sign them up on the spot. "Now let me talk first on the middle income group and the market reforms we decided to put in place. I won’t go into this in great depth, but the existing program in our state had all sorts of regulations and we made a number of reforms. We combined our individual and small group pools so we could pool more individuals to purchase insurance on a cost effective basis. We expanded Health Savings Account options. We encouraged provider networks. They had been discouraged before and a number of other things made us more competitive. "Now I’d also note that I wanted to do more in terms of reforms. I wanted to get rid of all mandates and the legislature said no and because there is 85 percent Democrats in my legislature they got the last word on that one. So we had some differences, but net we put in place a number of reforms and let me show you what the impact was on premiums. I’m going to use it as an example; an uninsured individual living in Boston, Massachusetts, 37 years old, male or female as we began this program. Costs of that premium for that individual would be approximately $335 a month. The deductible was $5,000, and there was no prescription drug – there was no drug coverage. Post-reform, the column on the right, the premiums went to $175 a month. The deductible was now 2,000, and prescription drugs were covered. So we got the prices down by deregulating our state market. "But they said there was another problem. The other problem, I remember, they said is no one wants to sell to them. They had a hard time getting serviced. And so we talked to our friends at the Heritage Foundation and they came up with a very interesting idea they were working on. We initially called it an exchange, then we changed the name to a Connector or the Legislature did – called it a Connector. But it basically was a little agency we set up that collected the premiums from individuals and passed it along to their insurance company. So we did the marketing and the processing with a little agency set up so that it could flow to and from the insurer and the insured. "And it had one more very important feature – and that’s at the bottom of the slide. By flowing that through this Connector, by flowing people’s premiums through our little state Connector we were able to qualify, under our Department of Labor Provisions, Section 125, so that their premiums could be tax deductible. So an individual buying their own insurance, in our state, let’s say a pizza shop worker that wanted to buy his or her own insurance was able to buy it and by virtue of this little set-up, buy it in federal dollar taxfree ability. And that made a difference.

"Now here comes the most controversial part of what we did. We said for middle-income citizens, now that we’ve got your premiums down, in some cases cut by as much as 50 percent, and now that we’ve got this Connector so that you can pay for premiums in pre-tax dollars, and now that we have insurance companies that were willing to deal with you, even though you’re a one or two person operation – now that we’ve done that, why is it you don’t have insurance? And we said, ‘You know what? We’re going to tell you, you either buy insurance or you pay your own way, no more showing up and getting free care.’ We said the end to free riders. And we call that a mandate. We say for people who can afford insurance, you either buy the insurance or you pay your own way. "Now my Legislature made a little change there too, they just said, ‘Hey, buy your own insurance, can’t pay your own way.’ I tried to change that, but we agreed to disagree. But in our state right now you buy your insurance if you’re making three times federal poverty or more – no more free ride. "Now how about low-income people? What do we do there? Well people typically, when they’re thinking about low-income folks say, ‘Well, in order to get more of them insured we’ve got to give more people Medicaid.’ And they go to the federal government and ask to put more people on Medicaid, but Medicaid is not a good insurance product. Medicaid was designed for the poor. And you know some of the reasons, one is Medicaid is 100 percent free. Let’s say you have a person that’s making 2.7 times federal poverty level, well is it fair that they don’t pay anything? No part of their premium at all. No co-pays, no deductible, just entirely free. And by the way, if they suddenly earn a little bit more money, if their employer gets them another $500 a year – bingo they’re no longer qualified and they lose all coverage, so whose ever going to go over that level. And by the way if you’re single and earning just under that level, but if you got married that would pushed your combined income above that level, you’d lose Medicaid, so let’s not get married. Think of the incentives we had in our system – Medicaid is not the right way, is not the right way to help people, the working poor get insurance. "So we’ve said instead, you know what we’re going to do, we’re going to help people buy their own private insurance, not Medicaid, not a government plan – private insurance. Go to the companies out there, pick the policy that you’d like, you pay what you could afford according to our sliding scale, and we’ll pick up the rest. It allows a sliding scale of what they’re paying and of course a glide path to self-sufficiency as their income gets up and up and up, they pay a larger share until finally they're paying the whole premium themselves. And the key thing here to make this work was this: We went to our friend in the federal government, we laid this plan out. We said instead of putting more people on Medicaid in the future we can get people insured with private insurance, but you know that money you send us to help care for the uninsured in our state? You know that money you send us? Would you let us use that money instead of going to payments to hospitals, and other providers, would you let us use that money to help people buy insurance instead? And Secretary Tommy Thompson, and Secretary Mike Leavitt, they looked long and hard and said yes. And it was Senator Kennedy and I, we did this on a bipartisan basis, we needed those dollars, those federal dollars and our state dollars, our matching funds to be allowed to help people buy insurance.

"And you know what? It costs less money to get people insured than it was costing us to hand out free care. Now let me just show you what the schedule looked like, so you can get a sense of what people were paying. This happens to be for a single person, and it’s actually a couple of years old – this is 2004 data – but it gives you a sense of it. Let’s say somebody’s earning $9,800 a year, what they pay for their health insurance – they pay nothing. No again, here’s another little difference between me and my Legislature. I wanted them to pay like a buck a week, but they said, ‘No, make it free.’ Well, they got the last word on that one. I thought everybody should pay something. But as you get a little higher, $14,700, people in that category, they’re going to pay $18 a month. Not a lot. The state picks up the rest and so forth. And when they get above 300 percent, the person is picking up their entire premium. And as a result people have an incentive to keep getting higher and higher incomes, and they’re paying for the portion of their premium which they can afford. "Now a couple of things. We didn’t blow up the system that already existed. We wanted to make sure we did no harm. Most people get their insurance through their employer, we didn’t want to end that. So we kept that program in place, so employers remain a cornerstone of health insurance in our state. But the individual market, people buying their own insurance, is now an option. Medicaid rate increase was given to doctors and hospitals to address the problem of cost-shifting. Cindy helped me on this, I think we went from 70 percent of the Medicaid rate for the Medicaid – we went from 70 percent to 95 percent. So we moved the reimbursement rate up to end the problem of the cost-shifting we had. And we also improved rates for community health centers. We needed more clinics as part of this plan. And we put in place a series of cost and quality initiatives – healthcare initiatives – one, we established a site for transparency information, we put in place prevention programs for a number of serious diseases and a very substantial health awareness program. So it was more than, if you will, just the care for the uninsured that were part of our plan. "And how are things going? Well it’s early to tell, but I like the signs. First for the people who are Medicaid eligible – we had 106,000 of those, remember? – we’ve signed up approximately 70,000 of those. So we made real good progress getting them signed up. People that were the working poor, one to three times the poverty level, we had about 150,000 of them. Approximately 105,000 have signed up. These are people who were uninsured, are now insured. That means they see a primary care physician, they get to a clinic, they get preventative care, they get better healthcare, and they’re now paying a portion of their premium – don’t forget that, I didn’t make that point as I went back here. See those dollars there, $18, $40, $70? These were people that used to go get free care, now they’re paying something. Now they know that their healthcare makes a difference to their pocketbook. They’re part of the system, that’s part of the revenue that came in – no more free ride. Everybody pays what they can afford. "And the final group, which are people earning over three times poverty level, the teeth in our enforcement mechanism don’t kick in until probably next April when they get their tax

bill because if they haven’t bought insurance, they’re charged $100 a month for not having bought insurance. So that’s just getting started. We’re getting people on their way. "Couple of principles: one you’ve got to reform the insurance market to get better products available to the consumer – lower priced products. Two, you have to have nondiscriminatory tax treatment for individuals, that’s why we put that connector in place – you don’t want to have companies getting a better deal. We felt it was important to have low-income purchase private insurance, not government care. And we used the money we were already spending to help care for the uninsured, we used that money to instead help people buy there own insurance. We brought everybody into the system and we created a mechanism to control cost and provide sustainability in the system. "Well the nation has some challenges too and I am going to draw from my Massachusetts experience and apply what I think we ought to do as a nation. First you know the cost of health insurance is rising sharply here as well across the country. I was in Manchester, New Hampshire, not too long ago. A young woman named Michelle Griffin, a waitress behind the counter, said she was insured. Both she and her husband both have insurance but she said the deductibles and the co-pays and the costs of premiums were basically getting beyond there reach. They had a child or two that were sick and she said we just can’t make ends meet anymore and she was highly emotional and I understood why. There are people all over the country wondering with premiums getting higher and higher. How can we afford to keep our health insurance but how can we possibly not care about our children. So we’ve got to find a way to get the cost of health insurance down. We have approximately 45 million people without insurance and that is a number which is frightening not only for them as I’ve described but for others who think they might fall into that category someday. There are a lot of people who fear that if they lose their job and particularly if they have a preexisting condition that there not going to get reinsured somewhere else. You have some employers around the country that thinks its just too expensive to keep up like the DeWolfe’s. I’ve got to drop coverage and finally you’re saying that spending at 17 percent GDP. "Now as we think about healthcare reforms at the national level, we’ve got to be careful and deliberate. The work we did in Massachusetts, we didn’t get a bunch of politicians in a room and say, 'Who wants to do this, this would be popular. Here’s an idea that will go over well with the media.' No, I got the head of a consulting firm. I got an old partner of mine from the venture capital world. I got an investment banker from J. P. Morgan. I got a professor from M.I.T. We worked with doctors, hospital administrators, other healthcare professionals, actuaries from the insurance world. I worked with some people that have government experience. A couple of them are here today. We worked together with folks to make sure what we did was done deliberately and carefully. Not stepping in to blow up a system where 93 percent in our state had insurance. We didn’t want to ruin that system. We wanted to care for the seven percent. "Not take the whole thing apart, to solve the problem of the seven. And so as you think about what we have to do nationally. The first rule is first do no harm. Don’t blow up the good we have in our system. We have the best quality healthcare in the world. We’re not

going to lose that. We are also the innovation capital of the world for healthcare. And we have positive tourist outcomes which is the envy of the world. The medical profession does attract from among the best and brightest, in all different levels of the medical field. Individuals have a choice and are able to guide their own care. Healthcare has provided access in rural markets. We want to make sure that continues in our country. We don’t want to destroy the large employer market. We have a lot of people who get their insurance from their employer and their happy with that. We don’t want to blow that up. And finally we do not want to have Europe like rationing telling our people they can’t get the care that they need and they afford. "Now my experience is that effective healthcare reform that’s going to reduce costs and get more people insured has to begin at the state level. Now why do I say that? Let me show you some information that is hard to pick it all out but this shows the average annual health insurance premium by state in the individual market meaning non family but individuals. This would give you a sense. California is less than $2,000 a year for an individual. New Jersey is over $6,000 for an individual. Florida is just under $3,000 for an individual and Massachusetts by the way is up there, we're that bright yellow. One of those over there, over $6,000 states before our reform. So very different insurance prices in different markets and why are the prices so differently. Well because the insurance market has different mandates, regulations, and requirements as a result of those differences the price of those policies is dramatically different. "What are the other differences between states? Well the percentage of uninsured is quite different. My state it was seven percent – in Texas it's 25 percent. So what works in Massachusetts probably won’t work in Texas. It’s going to need a different plan and in Florida you’re approximately 20 percent uninsured. So you’re seeing some pretty big variations between different states. How about the percentage of population over 65 years of age? Again – yeah you have a significant number there. And that we turn the percent receiving Medicaid by state – Maine, Vermont, Mississippi, over 20 percent of the people are receiving Medicaid care. You're somewhere between 10 percent to 13 percent that are on Medicaid. And so as I look at that and consider the experience I have had throughout my life. I recognize that the principle of federalism Teddy Roosevelt fought so hard for is needed in healthcare. "A one-size-fits-all national healthcare system is bound to fail. It ignores the very dramatic differences between states and it relies on a Washington bureaucracy to manage. You think about this, I do not want the guys that ran the Katrina clean up running our healthcare system. So in my view, healthcare reform has to take a federalist approach and the federalist role is to facilitate and encourage reforms like Tommy Thompson and Mike Leavitt did for us. Giving us flexibility in our funding so we can create our own program but we don’t mandate those reforms. We let states decide how they craft their own program. States are able to craft programs to match their unique needs and of course we let states remain as the laboratories of innovation. And by the way, I like the plan we came up with in Massachusetts. I wouldn’t be surprised if other states say I like that way I’m going to copy it and I’d be proud if they did. Some states will find they’ve got better answers than what we came up with and if they do hats off to them. We’ll all copy them but I like

with what we came up with but I will let other states make their own choice and let them decide whether our plan is right for them or whether they’ve got better ideas. "Now let me just remind you the things we’re trying to do: one, get the costs down; two, get everybody insured; three, make sure people don’t worry about losing insurance; and four reduce the growth rate of healthcare spending. And the outline to get that done has six major points. Number one is establish federal incentives to deregulate and reform health insurance markets. Two, redirect federal spending on ‘free care’ to help the low-income uninsured purchase private insurance. Three, institute HSA enhancements and finally give full deductibility of all qualified medical expenses. Promote innovation in Medicaid. Implement medical liability reform and bring market dynamics to healthcare. You like that. Good. Thank you. Thank you. "We’re going to go one by one here. We’ve got to deregulate and reform some of our state insurance markets – some more than others. Each state can decide how much they want to do. But the overregulation of state health insurance markets drives up the cost of coverage and dissuades people of middle incomes from buying coverage. And I mentioned this, California’s got their rate down to $1,885 a year for an individual. That’s the average. And New Jersey, given all their regulations is $6,000 a year. No wonder you’re going to have a lot of people in New Jersey that don’t buy insurance at that high a level. "And there are a lot of mandates of course, mandate in the broadest sense – regulations and overregulation that drive up the cost of insurance. Community rating, direct access to specialists, mandated benefits, guaranteed issue, any willing provider, health plan liability, provider due process – some of these by the way I like, and we put in our final plan, some I don’t. States can pick and choose among them. But they overall can become a very expensive burden on our health insurance market, and do what I just described, which is create very different prices among different states for health insurance. And therefore, we’re going to have to create federal incentives, and I’ll talk about what they are – federal incentives to states for the state to deregulate and reform their own health insurance market. States reform their market to reduce insurance premiums and to facilitate consumer choice. The federal incentive is this: we’ll give states access to federal funds that help them in their low-income uninsured program. We’ll give them that flexibility that Tommy Thompson and Mike Leavitt gave to us – we’ll give them the same flexibility – but only if they put in place the reforms that get the price of policies down. "Now by the way there’s an alternative that people talk about. Why not just let people by insurance from any state they want to? Why not say to the people in New Jersey, for instance, ‘Hey, we’re going to have a federal law that says New Jersey can’t keep you from buying a policy from California, say.’ And that, that has good features, and there’s nothing really wrong with it, but there are a couple I’d mention. "One is that you’d lose the benefit of the directed networks that California has, that’s by the way, one of the reasons their premiums are so low. And you’d also have some difficulty handling the problems if an insurer didn’t perform. How do you know if that’s a real insurance company if it comes from some other place? And if they don’t pay up when

they’re supposed to, and you’re in New Jersey, how do you get somebody in California, Vermont or wherever to pay up? So there are some problems. The biggest concern I have is this: it’s a big statement by the federal government. If the federal government comes in and says, ‘Look – we’re going to usurp the right of the state to decide who sells insurance in the state, and tell all of you you must accept policies from any state.’ You know what comes next – someone’s going to say, ‘Well, who’s going to regulate this? Who’s going to regulate these national companies? Well, we’ll have the federal government, of course, we’ll set up a regulator.' Then the federal government is going to be told, ‘Well, you’ve got to decide what’s a good policy, and not a good policy.’ So the federal government will start telling you what has to be in a policy. And that’s why I call it the camel’s nose under the tent – I get nervous when we start giving to the federal government more authority, more responsibility, because ultimately they want to end up running everything. So my first objective, and the first priority is let’s help state’s reform their markets so we can get prices down. "Let’s turn to a second issue, the uninsured. Who are the uninsured? You’ve heard we’ve got 45 million people without insurance, but just like Massachusetts they’re not all the same. Roughly 14.7 million, that’s the portion in yellow, are people who are eligible for current government programs and have never signed up. Now by the way, there are some people who believe a lot of those folks have signed up and the statistics just aren’t right and therefore the 45 million total isn’t right either. But at least about 15 million of the 41 million are people that don’t need other help, they’re already able to receive federal support. "And then you also look at the middle income. We’ve got about 11 million that are earning over 300 percent of the federal poverty level, another 7 million that are 2 to 300 percent over the federal poverty level. So we’ve got some 18 million who, depending on the state and cost of insurance, ought to be able to buy their own insurance. We only have about 12 million, 12 to – it depends on that 7 million number in the middle there – 12 million to 19 million that are going to need help of some kind to get insurance. So as we think about covering these folks, we’ve got to recognize that the problem is not getting 45 million insured, if you will, a subsidy program for 45 million – no, it’s a program to help those 12 million or perhaps as many as 19 million. And how do you go about doing that? Well you do just as Tommy Thompson and Mike Leavitt did for us, you permit states to redirect existing state and federal resources, that are now being sent out by them, to instead help low income people purchase their own private insurance. And you let states craft their own programs just like we did in Massachusetts. And they can do what we did. They can have the sliding scale just like we did. And if they want to they can have the mandate that we had. I think it’s a good idea. Other states may decide to take another path. But they will create their own programs to get their populations insured. And here’s a key point. We spend tens of billions of dollars right now at the state and federal level sending payments out to give care to the uninsured. We’re going to redirect that money to help people buy insurance and it will not cost us more money. And the reason is because we’re only dealing with 12-19 million people, not 45 million, and we do not need new spending and new taxes.

"Let’s talk about taxes for a minute. The tax code penalizes individuals that don’t get insurance through their employer, as we’ve described. And as a result of that, there really isn’t a robust consumer driven health insurance market in this country. The tax code also creates an incentive for over-insurance. Let me describe why that is. If you’re an employee signing up for an insurance plan, you know that if you get a plan that has high deductibles and high co-pays, that those high deductibles and high co-pays aren’t tax deductible. So, you prefer instead to get a plan that has very low deductibles and low copays because those things aren’t deductible. Individuals therefore don’t get exactly the plan they’d have the insurance – excuse me – the tax code is driving them to a policy that’s got huge premiums, but not the kind of deductibles that would otherwise make sense, and leads to unnecessary and excessive spending. The answer, enhance HSAs. Eliminate the minimum deductible requirement in HSAs. Number two, full deductibility of all qualified medical expenses, that means the whole thing – premiums, contributions to premiums, outof-pocket spending, deductibles, and co-payments. "Now of course to get the full deductibility people have to have at least a catastrophic coverage policy. This will help reduce the cost of healthcare for everybody, because they’re not only getting the deduction of their premium, they’re getting their deduction in their co-pays and their deductibles and other medical expenses. It will also create a consumer market, because for the first time, companies will be happy to sell directly to individuals because individuals don’t care if they buy their product through their employer or if they get it individually. Some 2-6 million people are estimated to purchase—be willing to purchase private coverage if we make this change. So we’ll get people who were uninsured into the insurance pool. "It promotes smarter healthcare spending because we now don’t disincentives people getting higher deduction policies. And finally, a study that was done by John Cogan and Glenn Hubbard suggests that this change will result in a 6.2 percent reduction in overall U.S. healthcare spending. "Now, how about Medicaid? I’d like to see us promote Medicaid improvements and reform. How do you do that? Well you know that federal Medicaid spending is out of control. $181 billion spent on Medicaid a day, to go to $417 by 2017, and because the state spending is matched, it makes it difficult to constrain expenditures. The states are also powerless to reform and innovate themselves because of the convoluted bureaucratic process in Washington, it takes months or even years for reforms to go through. And of course the restrictions by Washington limit innovation. The answer here is to give states complete and full flexibility to structure their Medicaid programs to meet the needs of their own people, and just block grant to them federal funding. Let states run their own Medicaid program. And by the way, that’s the same approach that we took in welfare reform. We said, 'States you create your programs, we’re going to block grant the money to you.' It has worked in welfare reform. It is time to work in Medicaid reform. The states have the incentive and the know-how to meet their citizens’ needs, to reign in unnecessary spending and to innovate. Florida, of course, has a voucher program going on now which is of great interest to all that are watching it Utah has a cost-sharing program for Medicaid recipients where they pick up a portion of the costs.

"States of course would be free to use their funding if they wanted to help the growth of private insurance by helping the low income people become insured, and of course states would be free of the extraordinary bureaucratic burden posed by Washington. "Now there’s another problem that you’re probably more familiar with than I—like all of the ones that I’ve talked about so far. And that’s the cost of malpractice premiums, which have sky-rocketed particularly over the last couple of years. This has a lot of negative implications. One of course is that a lot of doctors are leaving certain areas of the country where the increase has been the greatest and it’s expensive to get insurance and that’s a cost that you have to pass along to everybody buying insurance and of course the cost of defensive insurance is certainly well in addition to the cost burden that’s associated with this malpractice explosion. And as a result, it’s time to enact federal caps on non-economic and punitive damages, end it. "I was afraid that was going to be unpopular in this room, but I’m glad. Lottery size awards and frivolous lawsuits by rich trial lawyers, but they put a huge burden on doctors on hospitals and through defensive medicine on the entire population and every citizen is paying an exorbitant cost for this kind of system and I would like to see other state reforms put in place as well. We would like to encourage health courts and alternative dispute resolution and sanctions associated with repeating frivolous lawsuits. "The sixth topic is too big given how much time I’ve already taken and so we’ll get another presentation in great depth at some point, but let me just make a couple of headline points. We need to bring some of the market dynamics that exist in the rest of the private sector to the health care world in a more abundant way. The regulatory burden that’s been placed on health care over time has stifled the kind of modernization, innovation, and consumer driven improvements that have propelled other parts of our private sector in this country. As you see there is limited information technology compared to the private sector. There are limited types of provider options in lots of parts of our country. Consumers are generally uninformed about their choices and alternatives and consumers often have no stake at all in the cost of health care once they hit their deductible threshold on their policy and these things just aren’t productive to create a market driven healthcare system. And so I would like to see us put in place a series of incentives to promote information technology and EMR to establish cost and quality transparency, to authorize more health savings products and co-insurance. I happen to be a big believer in co-insurance. Back to the future if you will, back in the ‘50s and ‘60s these people use to take a percentage of their health care costs and pay that percentage all the way up. It made people care about how much something was going to cost and how well they were. I would also like to establish more provider options. Look market dynamics have sharply improved the cost and quality of America’s other goods and services and rather than socialize medicine and allow the government bureaucrats to run our healthcare system, we should instead bring in the dynamics of a free market system into healthcare to make it even more robust. "Now let me just tell you what we’ve done. At the beginning you must have said, well you must have said that this can’t get done. There’s no way the guy’s going to be able to get

health insurance costs down, get more people insured, all of the ultimately at the risk of losing insurance, and then reducing the growth of healthcare spending, but we have. We can make insurance more affordable for all Americans first by having full tax deducibility of all medical expenses, by reforming state insurance markets to get more affordable products, by reforming medical liability, and by putting in place some of the technology and free market dynamics that I described. "We can get every American insured by making sure that we have affordable policies for middle-income Americans. That by doing the things in number one there. And by putting in place a premium assistance program, a support program for low income individuals. Fashion state by state and I hope that a lot of people copy the Massachusetts plan or come up with one better, but we’re going to get everyone insured. Number three: we’re going to end the risk of losing insurance because we’re going to now have an individual market, where people can buy their own insurance if they want to and keep it from job to job to job. And if they worry about becoming poor we’re going to have in place a support program for low income individuals to make sure that they keep their insurance. And finally to the means that I have just described, we can reduce the growth that U.S. healthcare is spending. "Now is this perfect? No, I don’t know how you come up with something that is perfect, but it’s a great step forward. A huge leap forward. We’re not going to let perfection become the enemy of the good. We can get our health insurance premiums down. We can reform our system such that states are finding a way to get all of their citizens insured. We can do it without a government takeover without socialized medicine. "I know that it’s going to have to be done on a bipartisan basis. That’s how we did it in my state. My legislature I said was 85 percent Democrat. How did we get our plan done? We both worked on it. We all take credit for it. Both sides deserve a lot of credit for it. When it was all said and done by the way and the vote of the legislature occurred – we have combine house and senate 200 legislators – it passed 198 to 2. We can make something like this work in this nation by giving states the flexibility to create their own plans and using out federal funds to help them in doing so. Now we don’t need to move towards socialized medicine or a government takeover. That is so frightening to me. I love what P.J. O’Rourke said. He said that if you think that if you think heal care is expensive now, just wait until it’s free. We’re not going in that direction. Instead conservative principles, republican principles, individual responsibility, individual initiative and a free market system. These are the principles that will allow health care to perform brilliantly, continue to do the great things that it’s done in the past, and take the miracle of American medicine to more and more homes in a more affordable way. Thank you so much for being here today, appreciate your help. Thank you”